CT characteristics of bronchopulmonary abnormalities caused by pepper aspiration

CT characteristics of bronchopulmonary abnormalities caused by pepper aspiration | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article CT characteristics of bronchopulmonary abnormalities caused by pepper aspiration Zhang-rui Liang, Bin-jie Fu, Yang Xiao, Yi-shi Li, Zhi-gang Chu This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-3175550/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Purpose: To investigate the computed tomography (CT) characteristics of bronchopulmonary abnormalities caused by pepper aspiration for improving diagnosis. Materials and methods: From January 2016 to September 2022, 28 adult patients with confirmed obstructive pneumonia caused by pepper aspiration were enrolled. The CT characteristics of bronchial changes and pulmonary lesions caused by pepper were analyzed and summarized. Results: Among the 28 patients, the most common symptom was cough (26, 92.9%), followed by expectoration (23, 82.1%). Bronchoscopy examination revealed that the pepper was mainly located in the right lower lobe bronchus (18, 64.3%), followed by the left lower lobe bronchus (5, 17.9%). In combination with bronchoscopy results, the pepper in bronchus was manifested as circular or V/U-shaped high density, localized soft tissue, and flocculent opacification in 8 (28.6%), 16 (57.1%), and 3 (10.7%) cases on CT images, respectively. The bronchial wall around the pepper was thickened with localized occlusion (19, 67.9%) and stenosis (9, 32.1%). Regarding the adjacent bronchi without pepper, extensive wall thickening with stenosis and/or occlusion were found in 23 (82.1%) cases. Distal pulmonary lesions frequently involved two or three segments (21, 75.0%) and mainly presented as patchy consolidation or atelectasis (24, 85.7%). Conclusion: In combination to history of eating pepper and clinical symptoms, bronchopulmonary abnormalities caused by pepper should be highly suspected if U/V shaped and annular high density or localized soft tissue density was detected in the lower lobe bronchus, with extensive bronchial wall thickening, stenosis, or occlusion, and consolidation or atelectasis in multiple distal lung segments. Obstructive pneumonia Foreign body Pepper Computed tomography Figures Figure 1 Figure 2 Figure 3 Key points In districts with habit of eating pepper, pepper aspiration is a potential cause of obstructive pneumonia. The inhaled pepper usually located in the lower lobe bronchus and resulted in extensive bronchial wall thickening and multiple lung segments abnormalities. Peppers in bronchus exhibited characteristic U/V-shaped or annular high density when they calcified, otherwise localized soft tissue density. Introduction Pneumonia is a common acute respiratory infection that affects interstitium, alveoli, and distal bronchial tree of the lung [ 1 ] . It includes infectious pneumonia (bacterial, viral, and fungal pneumonia), radiation pneumonia, aspiration pneumonia, obstructive pneumonia, etc [ 2 – 5 ] . There are substantial differences in the clinical manifestations, treatment, and outcomes in obstructive pneumonia and other common infectious pneumonia [ 6 , 7 ] . Due to the presence of persist obstruction, obstructive pneumonia seldom resolves completely, and recurrent or refractory infections are frequent [ 6 ] . Obstructive pneumonia is generally caused by neoplasms and foreign bodies [ 7 – 10 ] . Foreign body obstruction is more diverse relative to obstruction caused by neoplasms. The most common foreign bodies are food items, such as fruit, vegetable pieces, seeds, meat, and bones [ 8 , 11 , 12 ] . Others include iatrogenic objects such as endodontic needles, tracheostomy tube segments, endotracheal tube appliances, and miscellaneous items such as thumbtacks, pins, rivets, etc [ 13 ] . Among them, a few foreign bodies such as coins, nails, and teeth are radiopaque, thus they appear hyperdense in computed tomography (CT) scan and can be easily detected and identified [ 8 , 14 – 16 ] . However, most organic foreign bodies are radiolucent and are unlikely to be detected directly by chest CT [ 8 , 12 , 15 , 17 ] . In some areas, due to the eating habits and customs, peppers in food may be incidentally inhaled into the lungs and cause obstructive pneumonia [ 14 ] . The irritable cough caused by the spicy stimulation of pepper makes this kind of foreign body easily to be ignored, and it is easily overlooked on radiological examinations due to the property of not radiopaque. It makes the diagnosis difficultly and the patients may suffer from recurrent or refractory pneumonia for a long time, so obstructive pneumonia caused by this reason requires further understanding. The previous reports on obstructive pneumonia caused by pepper aspiration are particularly sparse and mainly consist of case reports or small case series, and its radiological characteristics was not well studied [ 14 , 18 ] . Therefore, this study retrospectively collected 28 patients with confirmed pepper aspiration in Chongqing (a district with a long history of eating pepper), analyzed the CT features of bronchopulmonary abnormalities caused by pepper, and summarized their characteristics for early diagnosis and further proper treatment. Methods Patients This single-center retrospective study was approved by the institutional review board of the First Affiliated Hospital of Chongqing Medical University. The requirement for written informed consent was waived. The Electronic Health Record was searched for patients who underwent bronchoscopy examination and were confirmed obstructive pneumonia caused by pepper aspiration from January 2016 to June 2022. The clinical and chest CT data were collected and analyzed. The inclusion criteria were as follows: 1) patients with pepper aspiration confirmed by bronchoscopy; 2) patients with complete clinical and CT data. The exclusion criteria was as follows: CT images with severe artifacts affecting the evaluation. Finally, 28 patients were included in this study. The patients’ demographic information, clinical symptoms and their duration, history of eating pepper and aspiration, treatments (antibiotic therapy), bronchoscopy results, and chest CT manifestations were reviewed and recorded. CT Examinations CT examinations were performed using one of the following scanners: SOMATOM Perspective (Siemens Healthineers, Erlangen, Germany), SOMATOM Definition Flash (Siemens Healthineers, Erlangen, Germany), or Discovery CT750 HD (GE Healthcare, Milwaukee, WI, USA). A breath-hold exercise was performed before patient’s image acquisition. It was obtained from the thoracic inlet to the costophrenic angle at the end of inspiration during a single breath-hold, with patient in a supine position. Non-contrast CT images were acquired using the following settings: tube voltage, 110–130 kVp; tube current, 50–140 mAs (reference mAs, using automatic current modulation technology); slice thickness, 5 mm; rotation time, 0.5 seconds; pitch, 1.0-1.1; and matrix, 512×512. Images were reconstructed at a slice thickness and slice interval of either 0.625 (GE scanner) or 1.00 (Siemens scanners) mm, using iterative reconstruction with a standard (GE scanner) or medium-sharp (Siemens scanners) algorithm. Of these, 17 patients underwent contrast-enhanced CT after plain scan with 70–100 mL (1.5 mL/kg) of nonionic iodinated contrast material at a flow rate of 3–3.5 mL/s followed by 30–50 mL saline solution at the same injection rate. The automatic bolus tracking method was used to detect the ascending aorta with a threshold of 150 Hounsfield units (HU) followed by a delay of 6 seconds before scanning. A delayed phase was performed at the 150th second after the injection of the contrast agent. Image analysis Combined with the results of bronchoscopy, patients' CT images were reviewed in lung (window level, − 600 HU; window width, 1500 HU) and mediastinal (level, 40 HU; width, 400 HU) window settings by two radiologists (with 5 and 11 years of experience in chest CT). The window width and window level were adjusted for displaying the foreign body. Multi-planar reconstruction (MPR) with/without volume rendering (VR) were performed to display the morphological features of foreign body. Any disagreements during the review were resolved by consensus. The CT features of bronchopulmonary abnormalities in patients were analyzed, which included the location of foreign body in different lobe and bronchus, manifestation of intraluminal foreign body, bronchial changes around the foreign body, involvement of adjacent bronchi without foreign body, features and involvement of obstructive pneumonia, pleural effusion (yes or no), hilar and/or mediastinal lymph node enlargement (yes or no), bronchial artery dilatation (present or absent) on enhanced CT images, and concurrent lesions in other lung field (present or absent). Results Patients’ clinical characteristics Among the 28 patients (mean age: 54 ± 11 years, range: 27–70 years), 10 (35.7%) were male and 18 (64.3%) were female. All the patients had a history of eating food with pepper, but only 6 (21.4%) individuals had a definite history of pepper aspiration. Regarding patients’ clinical symptoms, the most common one was cough (26, 92.9%), followed by expectoration (23, 82.1%) and fever (3, 10.7%). Their clinical symptoms lasted from 2 weeks to 8 years and worsened in 14 (50.0%) cases in recent days. Of 17 patients who underwent antibiotic therapy, the clinical symptoms were relieved in 11 (64.7%) cases after treatment (Table 1 ). Table 1 Patients’ clinical characteristics and bronchoscopy findings (n = 28) Parameters Values Age (years) (range) 54 ± 11 (27–70) Gender Female 18 (64.3) Male 10 (35.7) Definite history of pepper aspiration 6 (21.4) Clinical symptoms Cough 26 (92.9) Expectoration 23 (82.1) Fever 3 (10.7) Hemoptysis or bloody sputum 4 (14.3) Efficacy of anti-inflammatory therapy 17 (60.7) Effective 11 (64.7) Invalid 6 (35.3) Distribution of foreign body Right lower lobe 18 (64.3) Left lower lobe 5 (17.9) Right middle lobe 4 (14.3) Left upper lobe 1 (3.6) Bronchoscopy findings Granulation tissue 24 (85.7) Purulent secretion 11 (39.3) Swelling of adjacent bronchus 12 (42.9) Pepper fragments 6 (21.4) Pepper shell 22 (78.6) Data are expressed as number (percentage) or mean ± standard deviation. Bronchoscopy findings Bronchoscopy examination indicated that the pepper frequently distributed in the right lower lobe (18 cases, 64.3%), followed by the left lower lobe (5 cases, 17.9%), right middle lobe (4 cases, 14.3%), and left upper lobe (1 case, 3.6%), and which mainly located in the segmental bronchus (18 cases, 64.3%), followed by lobar bronchus (6 cases, 21.4%) and sub-segmental bronchus (4 cases, 14.3%). In the involved bronchi, the complete pepper shell and pepper fragments were found in 22 (78.6%) and 6 (21.4%) cases, respectively. Granulation tissue around the pepper, purulent secretion (Fig. 1 d, 2 - 3 e), and swelling of adjacent bronchi were detected in 24 (85.7%), 11 (39.3%), and 12 (42.9%) cases, respectively (Table 1 ). CT findings of pepper and adjacent bronchi Patients’ CT characteristics of pepper and adjacent bronchi were list in Table 2 . In combination with bronchoscopy results, the intraluminal pepper in one patient (3.6%) could not be located on CT images, while that in other patients was shown as circular or U/V-shaped high density (8 cases, 28.6%) (the median [interquartile range] duration of symptoms: 365 [2069] days), localized soft tissue (16 cases, 57.1%) and flocculent (3 cases, 10.7%) opacification (240 [275] days). Wall thickening, occlusion, and stenosis of the bronchi with pepper were detected in 28 (100%), 19 (67.9%), and 9 (32.1%) patients, respectively (Fig. 1 – 3 , a-c). For the adjacent segmental or sub-segmental bronchi without pepper, wall thickening with stenosis and/ or occlusion was detected in 23 (82.1%) patients. Table 2 CT characteristics of pepper and adjacent bronchi CT findings n (%) Foreign body manifestations Localized soft tissue density 16 (57.1) High density 8 (28.6) Flocculent opacification 3 (10.7) Unclear 1 (3.6) abnormalities of the bronchi with pepper Thickened bronchial wall with lumen stenosis 9 (32.1) Thickened bronchial wall with lumen occlusion 19 (67.9) abnormalities of adjacent bronchi without pepper Thickened bronchial wall with lumen stenosis and/ or occlusion 23 (82.1) No change 5 (17.9) Data are expressed as number (percentage). CT findings of obstructive pulmonary lesions Obstructive pulmonary lesions involved 1, 2, 3, and 4 segments in 6 (21.4%), 10 (35.7%), 11 (39.3%), and 1 (3.6%) patients, respectively (Table 3 ). Among the involved segments, lateral basal segment of lower lobe (20, 71.4%) was the most common. The main CT manifestations of obstructive pulmonary lesions included consolidation or atelectasis, bronchiectasis with or without infection, and strip-shaped opacification in 24 (85.7%), 3 (10.7%), and 1 (3.6%) patients, respectively (Fig. 1 - 3 a-c, 23d). Among the 24 patients with consolidation or atelectasis, 12 (50.0%) had bronchiectasis with mucus plugs in the lesions. Table 3 Characteristics of obstructive pneumonia and other features on CT CT findings n (%) Main manifestations of obstructive pulmonary lesions Consolidation or atelectasis 24 (85.7) Bronchiectasis 3 (10.7) Stripe-shaped opacification 1 (3.6) Number of involved lung segments 1 6 (21.4) 2 10 (35.7) 3 11 (39.3) 4 1 (3.6) Bronchial changes in the involved segments Unclear 4 (14.3) Normal bronchus with mucus plugs 9 (32.1) Bronchiectasis with mucus plugs 15 (53.6) Changes of involved lung lobe in volume No change 7 (25.0) Decrease 21 (75.0) Pleural effusion 2 (7.1) Hilar and/or mediastinal lymph node enlargement 22 (78.6) No 0 (0.0) Only hilar lymph node enlargement 14 (50.0) Only mediastinal lymph node enlargement 0 (0.0) Hilar and mediastinal lymph node enlargement 8 (28.6) Bronchial artery dilatation 11/ 17 (64.7) Concurrent inflammation in other lung fields 2 (7.1) Data are expressed as number (percentage). Other findings on chest CT Pleural effusion, hilar and/or mediastinal lymph node enlargement, and concurrent inflammation in other lung field were detected in 2 (7.1%), 22 (78.6%), and 2 (7.1%) cases, respectively (Table 3 ). Among the 8 patients with simultaneous hilar and mediastinal lymph node enlargement (Fig. 3 b), 6 (75.0%) had only subcarinal lymph node enlargement in mediastinum. Bronchial artery dilatation was detected in 11 (64.7%) of the 17 patients with enhanced CT data. Discussion As for foreign body aspiration, clear history of inhalation and special clinical manifestations are helpful for confirming the diagnosis. However, few cases in the present study had an exact history of aspiration, and their clinical manifestations were atypical because eating pepper could also cause cough, thus the definite diagnosis was difficult. Although the clinical manifestations are atypical, which tend to gradually worsen in some patients and some cases may have poor results with conventional treatment. Therefore, the possibility of obstructive pneumonia should be considered. The bronchopulmonary abnormalities caused by pepper aspiration were found to have some characteristics on CT images, which mainly manifested as U/V-shaped or annular high density or localized soft tissue density in the lower lobe bronchus, extensive wall thickening with stenosis or occlusion in the surrounding bronchi, and consolidation or atelectasis in the multiple distal lung segments. Previous studies have reported that foreign body in adult patients was more frequently located in the right bronchus tree, especially the right lower bronchus [ 11 , 14 , 15 , 19 , 20 ] . In this study, the most common site of pepper impaction was also the right lower lobe bronchus, which is consistent with previous results. The higher frequency of aspiration into the right bronchial tree appears to be due to the vertical nature of right main bronchus, larger diameter, and the greater airflow through it [ 19 , 21 ] . In addition, most of the cases were found with pepper segments but not pepper fragments. This may be related to the different sizes of pepper, the bigger pepper segments are more difficult to be coughed up than the smaller fragments. The clinical manifestations of foreign body aspiration can vary, depending on the degree and duration of obstruction, as well as the size and location of the foreign body [ 12 ] . The most common symptom is cough, other symptoms include choking, vomiting, cyanosis, wheezing, stridor, dyspnea, chest pain, hemoptysis, sneezing, fever, and sputum [ 12 – 15 , 22 , 23 ] . In this study, the most common symptoms were cough and sputum, while the others were relatively rare. The reason for this may be due to the active ingredient of pepper, which can also induce respiratory symptoms. Moreover, the pepper was soft and hollow, the taper-like pepper or tiny fragments were seldom lodged in the tracheal or main bronchus, so symptoms like choking and wheezing were rare. In addition, after antibiotic treatment, the patients' chronic respiratory symptoms may recurrent or do not improve significantly. Because of ignorance or neglect, the aspiration event might be covered up by an accompanying cough that was mistakenly attributed to the stimulation of pepper. Therefore, it is difficult to make a diagnosis by symptoms alone, but there is a possibility of obstructive pneumonia. The positive detection of foreign bodies on CT images largely depends on the physical properties of the aspirated material and the slice thickness [ 16 ] . Substances like radiopaque materials are more easily detected, such as metals and bones [ 8 ] . Organic food items are the most commonly aspirated foreign bodies [ 13 , 24 ] . Due to their radiolucent nature, they cannot be directly detected on CT [ 8 , 13 ] . In this study, in combination with the bronchoscopy findings, it was revealed that a small proportion of pepper showed circular or U/V-shaped high density, which may be related to the occurrence of calcification in it. This manifestation is more specific because the shape of pepper could be described. In contrast, more intraluminal peppers showed as localized soft tissue density or flocculent opacification, which may be a manifestation of pepper mixed with surrounding granulation tissue and contained secretions. This unspecific manifestation needs to be distinguished from early bronchogenic carcinoma. Previous studies have found that the latter had mostly a hilar location, and commonly manifested as endobronchial nodular protrusion without extensive bronchial thickening [ 25 – 27 ] . Additionally, persistent endobronchial focal soft tissue density or flocculent opacification without enhancement should also be considered as a possibility of foreign body obstruction. In addition to the pepper itself, changes of surrounding structures also need to be noticed. In this study, the bronchi adjacent to pepper were extensively involved and presented as significant bronchial wall thickening with lumen stenosis or occlusion. These changes may be related to the long-lasting stimulation of pepper and recurrent inflammation. Moreover, the obstructive pulmonary lesions were consistent with the bronchial involvement, which manifested as multiple segmental consolidation or atelectasis with or without bronchiectasis. Previous studies also reported that obstructive pneumonia included bronchiectasis and bronchiolectasis with mucous plugging, a variety of parenchymal inflammatory changes, and significant atelectasis [ 5 ] . Therefore, when looking for the cause of protracted segmental consolidation or atelectasis with or without bronchiectasis, more attention should be paid to the proximal bronchi and their patency. Previous studies have reported that other features caused by foreign bodies included hilar lymph node enlargement and pleural effusion, especially the former [ 11 , 14 – 16 , 28 ] , which were most likely secondary to the long-term recurrent infection [ 29 ] . In this study, the majority of patients also had regional lymph node enlargement, while few cases had pleural effusion. Bronchiectasis usually occurs secondary to chronic or recurrent infection, which could lead to bronchial artery dilatation [ 30 ] . In this study, bronchial artery dilatation was present in most patients who underwent enhanced CT scan, which also indicated the chronic process of pulmonary lesions. Therefore, pulmonary lesions with regional lymph node enlargement and bronchial artery dilatation indicates the higher possibility of chronic inflammation rather than tumors. This study has several limitations. First, some peppers without normal shape or color are difficult to be identified, which leads to a relatively small sample size in present study. Second, not all peppers could be visualized on CT images directly unless calcification occurred in them because they were frequently surrounded by granulation tissue. Thus, the present findings may be more applicable to the district or people with specific dietary history. Third, the value of enhanced CT images in identifying bronchopulmonary lesions caused by pepper is unclear because enhanced CT scan was not performed in all the patients. Conclusion In conclusion, the bronchopulmonary abnormalities caused by pepper aspiration were found to have some characteristics in this study. In the district where peppers are popular, in combination to the history of eating pepper and clinical symptoms, obstructive pneumonia due to pepper aspiration should be suspected if U/V-shaped or annular high density or localized soft tissue density in the lower lobe bronchus, with extensive wall thickening, stenosis, and occlusion of the surrounding bronchi, and consolidation or atelectasis in multiple distal lung segments. For the suspected patients, further bronchoscopy examination may be proper for confirming and treating or excluding other possibilities. Declarations Ethical Approval This study conformed to the Declaration of Helsinki on Human Research Ethics standards and was approved by the institutional review board of the First Affiliated Hospital of Chongqing Medical University (number 2019–062). The need for written, informed consent was waived by the institutional review board of the First Affiliated Hospital of Chongqing Medical University because of the retrospective design. Competing interests The authors declare that they have no competing interests. Authors’ contributions ZRL and BJF collected, analyzed, and interpreted the patient data, and were equal major contributors in writing the manuscript. YX and YSL provided the study materials and data, and wrote the manuscript. ZGC monitored the process of the study, made conception, and designed the research and modified the manuscript. All authors read and approved the final manuscript. Funding This work was supported by the Joint Project of Chongqing Science and Technology Commission and Chongqing Public Health Commission (2022MSXM050), and the Senior Medical Talents Program of Chongqing for Young and Middle-aged from Chongqing Health Commission (Receptor: Zhigang Chu) Availability of data and materials The datasets used and/or analyzed during the current study are not publicly available because the cases are from the Picture Archiving and Communicating System of our Hospital but are available from the corresponding author on reasonable request. References Torres A, Cilloniz C, Niederman MS, et al. Pneumonia [J]. Nat Rev Dis Primers. 2021;7(1):25. Lanks CW, Musani AI, Hsia DW. Community-acquired Pneumonia and Hospital-acquired Pneumonia [J]. Med Clin North Am. 2019;103(3):487–501. Neill S, Dean N. Aspiration pneumonia and pneumonitis: a spectrum of infectious/noninfectious diseases affecting the lung [J]. Curr Opin Infect Dis. 2019;32(2):152–7. 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Walker CM, Rosado-de-Christenson ML, Martínez-Jiménez S, et al. Bronchial arteries: anatomy, function, hypertrophy, and anomalies [J]. Volume 35. Radiographics: a Review Publication of the Radiological Society of North America, Inc; 2015. pp. 32–49. 1. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-3175550","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":219705728,"identity":"ad016722-d9d3-42ed-9ac6-76fc29b371d4","order_by":0,"name":"Zhang-rui Liang","email":"","orcid":"","institution":"First Affiliated Hospital of Chongqing Medical University","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Zhang-rui","middleName":"","lastName":"Liang","suffix":""},{"id":219705729,"identity":"8acbd398-b722-43cc-bb73-26fc1241fb02","order_by":1,"name":"Bin-jie Fu","email":"","orcid":"","institution":"First Affiliated Hospital of Chongqing Medical University","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Bin-jie","middleName":"","lastName":"Fu","suffix":""},{"id":219705730,"identity":"00b75bad-3957-42a0-a135-8c6457c9a4ae","order_by":2,"name":"Yang Xiao","email":"","orcid":"","institution":"First Affiliated Hospital of Chongqing Medical University","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Yang","middleName":"","lastName":"Xiao","suffix":""},{"id":219705731,"identity":"e6312ec9-74fc-44ba-9876-5da2f718474b","order_by":3,"name":"Yi-shi Li","email":"","orcid":"","institution":"First Affiliated Hospital of Chongqing Medical University","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Yi-shi","middleName":"","lastName":"Li","suffix":""},{"id":219705732,"identity":"9701d55a-af83-48ad-ac3b-7bf5d56402d3","order_by":4,"name":"Zhi-gang Chu","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAzUlEQVRIiWNgGAWjYDACCRBhYMNj397Y+PAD8Voq0mQMeA43G0sQr+XMYRsDifQ2AR5idPDP7jH++LUtjcdc8mEbUL+dnG4DIUvunDEwlm2z4bGcndj2oIAh2djsAAEtBhI5BsmSQFsYbie2G0gwHEjcRoyWw5Jth3kYbh5sk+AhUoth44czh3kMbjASqUXiRloxMzCQeSR7EoGBbECEX/hnJG/++MPAxp6f/fjDhx8q7OQIagEBZkR0GBChHAQYfxCpcBSMglEwCkYoAABr9UFOEdDYGAAAAABJRU5ErkJggg==","orcid":"","institution":"First Affiliated Hospital of Chongqing Medical University","correspondingAuthor":true,"submittingAuthor":false,"prefix":"","firstName":"Zhi-gang","middleName":"","lastName":"Chu","suffix":""}],"badges":[],"createdAt":"2023-07-16 16:44:17","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-3175550/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-3175550/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":40479167,"identity":"cd420f63-e66a-4ebc-91f8-be6e8dd7c07a","added_by":"auto","created_at":"2023-07-24 14:27:51","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":1001660,"visible":true,"origin":"","legend":"\u003cp\u003eA 56-year-old woman with cough and expectoration for 2 years and no definite history of pepper aspiration. Axial (a) and coronal (b) CT images show annular (red arrow) and V-shaped (red arrow) high density in the outer basal segment bronchus of the right lower lobe and atelectasis. Sagittal enhanced CT image showsthe thickened bronchial wall adjacent to foreign body and bronchiectasis with mucus plugs (arrows) in atelectasis (c). Bronchoscopy examination shows purulent secretion (d, arrow) and white foreign body (e, arrow) in the opening of the bronchus. Finally, the foreign body is revealed as pepper shell (f).\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-3175550/v1/7213ec5f20667d599b0c9c64.png"},{"id":40479168,"identity":"4ff41516-4128-4372-9fdf-2ee293867cf3","added_by":"auto","created_at":"2023-07-24 14:27:51","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":894563,"visible":true,"origin":"","legend":"\u003cp\u003eA 47-year-old man with cough and expectoration for 8 years and definite history of pepper aspiration. Axial CT images show annular (red arrow) high density in the antero-medial basal segment bronchus of the left lower lobe (a) and bronchiectasis and consolidation (b). Coronal enhanced CT image (c) showsthickened bronchial wall adjacent to U-shaped high density foreign body and bronchial artery dilatation (arrows). Volume rendering image (d) shows occlusion of the bronchus with foreign body (arrow) and distal extensive bronchiectasis. Bronchoscopy examination shows purulent secretion mixed with red foreign body (e) in the opening of the bronchus. Finally, the foreign body is revealed as pepper shell (f).\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-3175550/v1/475aed8d1a9d93eb7199832e.png"},{"id":40479169,"identity":"03c45a15-9187-4b11-a362-9638b492db9b","added_by":"auto","created_at":"2023-07-24 14:27:51","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":1049556,"visible":true,"origin":"","legend":"\u003cp\u003eA 70-year-old woman with cough and expectoration for 6 months and definite history of pepper aspiration. Coronal CT image shows localized soft tissue density opacification (arrow) at the opening of anterior basal segment bronchus of the right lower lobe (a). On axial CT image, it has no significant enhancement (arrow), and enlarged lymph node (asterisk) at right hilum(b) as well as distal consolidation and nodules could be detected (c). Volume rendering image (d) shows occlusion and stenosis (arrow) of the right lower lobe bronchi and distal bronchiectasis. Bronchoscopy examination shows red foreign body containing secretion (e) in the opening of the bronchus. Finally, the foreign body is revealed as pepper shell (f).\u003c/p\u003e","description":"","filename":"3.png","url":"https://assets-eu.researchsquare.com/files/rs-3175550/v1/6d0e3e0739284b70e7bd6f0c.png"},{"id":53210520,"identity":"e7b50366-5489-4c15-aff9-5b14331cbe54","added_by":"auto","created_at":"2024-03-22 01:29:42","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":2998273,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-3175550/v1/6134c2ce-ae41-44b3-b5f2-644acf823b15.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"CT characteristics of bronchopulmonary abnormalities caused by pepper aspiration","fulltext":[{"header":"Key points","content":"\u003col\u003e\n \u003cli\u003eIn districts with habit of eating pepper, pepper aspiration is a potential cause of obstructive pneumonia.\u003c/li\u003e\n \u003cli\u003eThe inhaled pepper usually located in the lower lobe bronchus and resulted in extensive bronchial wall thickening and multiple lung segments abnormalities.\u003c/li\u003e\n \u003cli\u003ePeppers in bronchus exhibited characteristic U/V-shaped or annular high density when they calcified, otherwise localized soft tissue density.\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Introduction","content":"\u003cp\u003ePneumonia is a common acute respiratory infection that affects interstitium, alveoli, and distal bronchial tree of the lung\u003csup\u003e[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]\u003c/sup\u003e. It includes infectious pneumonia (bacterial, viral, and fungal pneumonia), radiation pneumonia, aspiration pneumonia, obstructive pneumonia, etc\u003csup\u003e[\u003cspan additionalcitationids=\"CR3 CR4\" citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]\u003c/sup\u003e. There are substantial differences in the clinical manifestations, treatment, and outcomes in obstructive pneumonia and other common infectious pneumonia\u003csup\u003e[\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]\u003c/sup\u003e. Due to the presence of persist obstruction, obstructive pneumonia seldom resolves completely, and recurrent or refractory infections are frequent\u003csup\u003e[\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eObstructive pneumonia is generally caused by neoplasms and foreign bodies\u003csup\u003e[\u003cspan additionalcitationids=\"CR8 CR9\" citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]\u003c/sup\u003e. Foreign body obstruction is more diverse relative to obstruction caused by neoplasms. The most common foreign bodies are food items, such as fruit, vegetable pieces, seeds, meat, and bones\u003csup\u003e[\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]\u003c/sup\u003e. Others include iatrogenic objects such as endodontic needles, tracheostomy tube segments, endotracheal tube appliances, and miscellaneous items such as thumbtacks, pins, rivets, etc\u003csup\u003e[\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]\u003c/sup\u003e. Among them, a few foreign bodies such as coins, nails, and teeth are radiopaque, thus they appear hyperdense in computed tomography (CT) scan and can be easily detected and identified\u003csup\u003e[\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan additionalcitationids=\"CR15\" citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]\u003c/sup\u003e. However, most organic foreign bodies are radiolucent and are unlikely to be detected directly by chest CT\u003csup\u003e[\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eIn some areas, due to the eating habits and customs, peppers in food may be incidentally inhaled into the lungs and cause obstructive pneumonia\u003csup\u003e[\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]\u003c/sup\u003e. The irritable cough caused by the spicy stimulation of pepper makes this kind of foreign body easily to be ignored, and it is easily overlooked on radiological examinations due to the property of not radiopaque. It makes the diagnosis difficultly and the patients may suffer from recurrent or refractory pneumonia for a long time, so obstructive pneumonia caused by this reason requires further understanding.\u003c/p\u003e \u003cp\u003eThe previous reports on obstructive pneumonia caused by pepper aspiration are particularly sparse and mainly consist of case reports or small case series, and its radiological characteristics was not well studied\u003csup\u003e[\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]\u003c/sup\u003e. Therefore, this study retrospectively collected 28 patients with confirmed pepper aspiration in Chongqing (a district with a long history of eating pepper), analyzed the CT features of bronchopulmonary abnormalities caused by pepper, and summarized their characteristics for early diagnosis and further proper treatment.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003ePatients\u003c/h2\u003e \u003cp\u003e This single-center retrospective study was approved by the institutional review board of the First Affiliated Hospital of Chongqing Medical University. The requirement for written informed consent was waived.\u003c/p\u003e \u003cp\u003eThe Electronic Health Record was searched for patients who underwent bronchoscopy examination and were confirmed obstructive pneumonia caused by pepper aspiration from January 2016 to June 2022. The clinical and chest CT data were collected and analyzed. The inclusion criteria were as follows: 1) patients with pepper aspiration confirmed by bronchoscopy; 2) patients with complete clinical and CT data. The exclusion criteria was as follows: CT images with severe artifacts affecting the evaluation. Finally, 28 patients were included in this study. The patients\u0026rsquo; demographic information, clinical symptoms and their duration, history of eating pepper and aspiration, treatments (antibiotic therapy), bronchoscopy results, and chest CT manifestations were reviewed and recorded.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eCT Examinations\u003c/h2\u003e \u003cp\u003eCT examinations were performed using one of the following scanners: SOMATOM Perspective (Siemens Healthineers, Erlangen, Germany), SOMATOM Definition Flash (Siemens Healthineers, Erlangen, Germany), or Discovery CT750 HD (GE Healthcare, Milwaukee, WI, USA). A breath-hold exercise was performed before patient\u0026rsquo;s image acquisition. It was obtained from the thoracic inlet to the costophrenic angle at the end of inspiration during a single breath-hold, with patient in a supine position.\u003c/p\u003e \u003cp\u003eNon-contrast CT images were acquired using the following settings: tube voltage, 110\u0026ndash;130 kVp; tube current, 50\u0026ndash;140 mAs (reference mAs, using automatic current modulation technology); slice thickness, 5 mm; rotation time, 0.5 seconds; pitch, 1.0-1.1; and matrix, 512\u0026times;512. Images were reconstructed at a slice thickness and slice interval of either 0.625 (GE scanner) or 1.00 (Siemens scanners) mm, using iterative reconstruction with a standard (GE scanner) or medium-sharp (Siemens scanners) algorithm. Of these, 17 patients underwent contrast-enhanced CT after plain scan with 70\u0026ndash;100 mL (1.5 mL/kg) of nonionic iodinated contrast material at a flow rate of 3\u0026ndash;3.5 mL/s followed by 30\u0026ndash;50 mL saline solution at the same injection rate. The automatic bolus tracking method was used to detect the ascending aorta with a threshold of 150 Hounsfield units (HU) followed by a delay of 6 seconds before scanning. A delayed phase was performed at the 150th second after the injection of the contrast agent.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eImage analysis\u003c/h2\u003e \u003cp\u003eCombined with the results of bronchoscopy, patients' CT images were reviewed in lung (window level, \u0026minus;\u0026thinsp;600 HU; window width, 1500 HU) and mediastinal (level, 40 HU; width, 400 HU) window settings by two radiologists (with 5 and 11 years of experience in chest CT). The window width and window level were adjusted for displaying the foreign body. Multi-planar reconstruction (MPR) with/without volume rendering (VR) were performed to display the morphological features of foreign body. Any disagreements during the review were resolved by consensus.\u003c/p\u003e \u003cp\u003eThe CT features of bronchopulmonary abnormalities in patients were analyzed, which included the location of foreign body in different lobe and bronchus, manifestation of intraluminal foreign body, bronchial changes around the foreign body, involvement of adjacent bronchi without foreign body, features and involvement of obstructive pneumonia, pleural effusion (yes or no), hilar and/or mediastinal lymph node enlargement (yes or no), bronchial artery dilatation (present or absent) on enhanced CT images, and concurrent lesions in other lung field (present or absent).\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003ePatients\u0026rsquo; clinical characteristics\u003c/h2\u003e \u003cp\u003eAmong the 28 patients (mean age: 54\u0026thinsp;\u0026plusmn;\u0026thinsp;11 years, range: 27\u0026ndash;70 years), 10 (35.7%) were male and 18 (64.3%) were female. All the patients had a history of eating food with pepper, but only 6 (21.4%) individuals had a definite history of pepper aspiration. Regarding patients\u0026rsquo; clinical symptoms, the most common one was cough (26, 92.9%), followed by expectoration (23, 82.1%) and fever (3, 10.7%). Their clinical symptoms lasted from 2 weeks to 8 years and worsened in 14 (50.0%) cases in recent days. Of 17 patients who underwent antibiotic therapy, the clinical symptoms were relieved in 11 (64.7%) cases after treatment (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003ePatients\u0026rsquo; clinical characteristics and bronchoscopy findings (n\u0026thinsp;=\u0026thinsp;28)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eParameters\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eValues\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge (years) (range)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e54\u0026thinsp;\u0026plusmn;\u0026thinsp;11 (27\u0026ndash;70)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGender\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e18 (64.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e10 (35.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDefinite history of pepper aspiration\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6 (21.4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eClinical symptoms\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCough\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e26 (92.9)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eExpectoration\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e23 (82.1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFever\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3 (10.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHemoptysis or bloody sputum\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4 (14.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEfficacy of anti-inflammatory therapy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e17 (60.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEffective\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e11 (64.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eInvalid\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6 (35.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDistribution of foreign body\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRight lower lobe\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e18 (64.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLeft lower lobe\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5 (17.9)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRight middle lobe\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4 (14.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLeft upper lobe\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (3.6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBronchoscopy findings\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGranulation tissue\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e24 (85.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePurulent secretion\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e11 (39.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSwelling of adjacent bronchus\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e12 (42.9)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePepper fragments\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6 (21.4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePepper shell\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e22 (78.6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"2\"\u003eData are expressed as number (percentage) or mean\u0026thinsp;\u0026plusmn;\u0026thinsp;standard deviation.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eBronchoscopy findings\u003c/h2\u003e \u003cp\u003eBronchoscopy examination indicated that the pepper frequently distributed in the right lower lobe (18 cases, 64.3%), followed by the left lower lobe (5 cases, 17.9%), right middle lobe (4 cases, 14.3%), and left upper lobe (1 case, 3.6%), and which mainly located in the segmental bronchus (18 cases, 64.3%), followed by lobar bronchus (6 cases, 21.4%) and sub-segmental bronchus (4 cases, 14.3%). In the involved bronchi, the complete pepper shell and pepper fragments were found in 22 (78.6%) and 6 (21.4%) cases, respectively. Granulation tissue around the pepper, purulent secretion (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003ed, \u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e-\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003ee), and swelling of adjacent bronchi were detected in 24 (85.7%), 11 (39.3%), and 12 (42.9%) cases, respectively (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003eCT findings of pepper and adjacent bronchi\u003c/h2\u003e \u003cp\u003ePatients\u0026rsquo; CT characteristics of pepper and adjacent bronchi were list in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e. In combination with bronchoscopy results, the intraluminal pepper in one patient (3.6%) could not be located on CT images, while that in other patients was shown as circular or U/V-shaped high density (8 cases, 28.6%) (the median [interquartile range] duration of symptoms: 365 [2069] days), localized soft tissue (16 cases, 57.1%) and flocculent (3 cases, 10.7%) opacification (240 [275] days). Wall thickening, occlusion, and stenosis of the bronchi with pepper were detected in 28 (100%), 19 (67.9%), and 9 (32.1%) patients, respectively (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e, a-c). For the adjacent segmental or sub-segmental bronchi without pepper, wall thickening with stenosis and/ or occlusion was detected in 23 (82.1%) patients.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eCT characteristics of pepper and adjacent bronchi\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCT findings\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003en (%)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eForeign body manifestations\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLocalized soft tissue density\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e16 (57.1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHigh density\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e8 (28.6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFlocculent opacification\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e3 (10.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUnclear\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1 (3.6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eabnormalities of the bronchi with pepper\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eThickened bronchial wall with lumen stenosis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e9 (32.1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eThickened bronchial wall with lumen occlusion\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e19 (67.9)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eabnormalities of adjacent bronchi without pepper\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eThickened bronchial wall with lumen stenosis and/ or occlusion\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e23 (82.1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo change\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e5 (17.9)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"2\"\u003eData are expressed as number (percentage).\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec10\" class=\"Section2\"\u003e \u003ch2\u003eCT findings of obstructive pulmonary lesions\u003c/h2\u003e \u003cp\u003eObstructive pulmonary lesions involved 1, 2, 3, and 4 segments in 6 (21.4%), 10 (35.7%), 11 (39.3%), and 1 (3.6%) patients, respectively (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). Among the involved segments, lateral basal segment of lower lobe (20, 71.4%) was the most common. The main CT manifestations of obstructive pulmonary lesions included consolidation or atelectasis, bronchiectasis with or without infection, and strip-shaped opacification in 24 (85.7%), 3 (10.7%), and 1 (3.6%) patients, respectively (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e-\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003ea-c, 23d). Among the 24 patients with consolidation or atelectasis, 12 (50.0%) had bronchiectasis with mucus plugs in the lesions.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eCharacteristics of obstructive pneumonia and other features on CT\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCT findings\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003en (%)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMain manifestations of obstructive pulmonary lesions\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eConsolidation or atelectasis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e24 (85.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBronchiectasis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e3 (10.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eStripe-shaped opacification\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1 (3.6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNumber of involved lung segments\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e6 (21.4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e10 (35.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e11 (39.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1 (3.6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBronchial changes in the involved segments\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUnclear\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e4 (14.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNormal bronchus with mucus plugs\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e9 (32.1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBronchiectasis with mucus plugs\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e15 (53.6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eChanges of involved lung lobe in volume\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo change\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e7 (25.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDecrease\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e21 (75.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePleural effusion\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2 (7.1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHilar and/or mediastinal lymph node enlargement\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e22 (78.6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0 (0.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOnly hilar lymph node enlargement\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e14 (50.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOnly mediastinal lymph node enlargement\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0 (0.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHilar and mediastinal lymph node enlargement\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e8 (28.6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBronchial artery dilatation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e11/ 17 (64.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eConcurrent inflammation in other lung fields\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2 (7.1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"2\"\u003eData are expressed as number (percentage).\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eOther findings on chest CT\u003c/h2\u003e \u003cp\u003ePleural effusion, hilar and/or mediastinal lymph node enlargement, and concurrent inflammation in other lung field were detected in 2 (7.1%), 22 (78.6%), and 2 (7.1%) cases, respectively (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). Among the 8 patients with simultaneous hilar and mediastinal lymph node enlargement (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003eb), 6 (75.0%) had only subcarinal lymph node enlargement in mediastinum. Bronchial artery dilatation was detected in 11 (64.7%) of the 17 patients with enhanced CT data.\u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eAs for foreign body aspiration, clear history of inhalation and special clinical manifestations are helpful for confirming the diagnosis. However, few cases in the present study had an exact history of aspiration, and their clinical manifestations were atypical because eating pepper could also cause cough, thus the definite diagnosis was difficult. Although the clinical manifestations are atypical, which tend to gradually worsen in some patients and some cases may have poor results with conventional treatment. Therefore, the possibility of obstructive pneumonia should be considered. The bronchopulmonary abnormalities caused by pepper aspiration were found to have some characteristics on CT images, which mainly manifested as U/V-shaped or annular high density or localized soft tissue density in the lower lobe bronchus, extensive wall thickening with stenosis or occlusion in the surrounding bronchi, and consolidation or atelectasis in the multiple distal lung segments.\u003c/p\u003e \u003cp\u003ePrevious studies have reported that foreign body in adult patients was more frequently located in the right bronchus tree, especially the right lower bronchus\u003csup\u003e[\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]\u003c/sup\u003e. In this study, the most common site of pepper impaction was also the right lower lobe bronchus, which is consistent with previous results. The higher frequency of aspiration into the right bronchial tree appears to be due to the vertical nature of right main bronchus, larger diameter, and the greater airflow through it\u003csup\u003e[\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]\u003c/sup\u003e. In addition, most of the cases were found with pepper segments but not pepper fragments. This may be related to the different sizes of pepper, the bigger pepper segments are more difficult to be coughed up than the smaller fragments.\u003c/p\u003e \u003cp\u003eThe clinical manifestations of foreign body aspiration can vary, depending on the degree and duration of obstruction, as well as the size and location of the foreign body\u003csup\u003e[\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]\u003c/sup\u003e. The most common symptom is cough, other symptoms include choking, vomiting, cyanosis, wheezing, stridor, dyspnea, chest pain, hemoptysis, sneezing, fever, and sputum\u003csup\u003e[\u003cspan additionalcitationids=\"CR13 CR14\" citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]\u003c/sup\u003e. In this study, the most common symptoms were cough and sputum, while the others were relatively rare. The reason for this may be due to the active ingredient of pepper, which can also induce respiratory symptoms. Moreover, the pepper was soft and hollow, the taper-like pepper or tiny fragments were seldom lodged in the tracheal or main bronchus, so symptoms like choking and wheezing were rare. In addition, after antibiotic treatment, the patients' chronic respiratory symptoms may recurrent or do not improve significantly. Because of ignorance or neglect, the aspiration event might be covered up by an accompanying cough that was mistakenly attributed to the stimulation of pepper. Therefore, it is difficult to make a diagnosis by symptoms alone, but there is a possibility of obstructive pneumonia.\u003c/p\u003e \u003cp\u003eThe positive detection of foreign bodies on CT images largely depends on the physical properties of the aspirated material and the slice thickness\u003csup\u003e[\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]\u003c/sup\u003e. Substances like radiopaque materials are more easily detected, such as metals and bones\u003csup\u003e[\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]\u003c/sup\u003e. Organic food items are the most commonly aspirated foreign bodies\u003csup\u003e[\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]\u003c/sup\u003e. Due to their radiolucent nature, they cannot be directly detected on CT\u003csup\u003e[\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]\u003c/sup\u003e. In this study, in combination with the bronchoscopy findings, it was revealed that a small proportion of pepper showed circular or U/V-shaped high density, which may be related to the occurrence of calcification in it. This manifestation is more specific because the shape of pepper could be described. In contrast, more intraluminal peppers showed as localized soft tissue density or flocculent opacification, which may be a manifestation of pepper mixed with surrounding granulation tissue and contained secretions. This unspecific manifestation needs to be distinguished from early bronchogenic carcinoma. Previous studies have found that the latter had mostly a hilar location, and commonly manifested as endobronchial nodular protrusion without extensive bronchial thickening\u003csup\u003e[\u003cspan additionalcitationids=\"CR26\" citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]\u003c/sup\u003e. Additionally, persistent endobronchial focal soft tissue density or flocculent opacification without enhancement should also be considered as a possibility of foreign body obstruction.\u003c/p\u003e \u003cp\u003eIn addition to the pepper itself, changes of surrounding structures also need to be noticed. In this study, the bronchi adjacent to pepper were extensively involved and presented as significant bronchial wall thickening with lumen stenosis or occlusion. These changes may be related to the long-lasting stimulation of pepper and recurrent inflammation. Moreover, the obstructive pulmonary lesions were consistent with the bronchial involvement, which manifested as multiple segmental consolidation or atelectasis with or without bronchiectasis. Previous studies also reported that obstructive pneumonia included bronchiectasis and bronchiolectasis with mucous plugging, a variety of parenchymal inflammatory changes, and significant atelectasis\u003csup\u003e[\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]\u003c/sup\u003e. Therefore, when looking for the cause of protracted segmental consolidation or atelectasis with or without bronchiectasis, more attention should be paid to the proximal bronchi and their patency.\u003c/p\u003e \u003cp\u003ePrevious studies have reported that other features caused by foreign bodies included hilar lymph node enlargement and pleural effusion, especially the former\u003csup\u003e[\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan additionalcitationids=\"CR15\" citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]\u003c/sup\u003e, which were most likely secondary to the long-term recurrent infection\u003csup\u003e[\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]\u003c/sup\u003e. In this study, the majority of patients also had regional lymph node enlargement, while few cases had pleural effusion. Bronchiectasis usually occurs secondary to chronic or recurrent infection, which could lead to bronchial artery dilatation\u003csup\u003e[\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]\u003c/sup\u003e. In this study, bronchial artery dilatation was present in most patients who underwent enhanced CT scan, which also indicated the chronic process of pulmonary lesions. Therefore, pulmonary lesions with regional lymph node enlargement and bronchial artery dilatation indicates the higher possibility of chronic inflammation rather than tumors.\u003c/p\u003e \u003cp\u003eThis study has several limitations. First, some peppers without normal shape or color are difficult to be identified, which leads to a relatively small sample size in present study. Second, not all peppers could be visualized on CT images directly unless calcification occurred in them because they were frequently surrounded by granulation tissue. Thus, the present findings may be more applicable to the district or people with specific dietary history. Third, the value of enhanced CT images in identifying bronchopulmonary lesions caused by pepper is unclear because enhanced CT scan was not performed in all the patients.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eIn conclusion, the bronchopulmonary abnormalities caused by pepper aspiration were found to have some characteristics in this study. In the district where peppers are popular, in combination to the history of eating pepper and clinical symptoms, obstructive pneumonia due to pepper aspiration should be suspected if U/V-shaped or annular high density or localized soft tissue density in the lower lobe bronchus, with extensive wall thickening, stenosis, and occlusion of the surrounding bronchi, and consolidation or atelectasis in multiple distal lung segments. For the suspected patients, further bronchoscopy examination may be proper for confirming and treating or excluding other possibilities.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cem\u003eEthical Approval\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThis study conformed to the Declaration of Helsinki on Human Research Ethics standards and was approved by the institutional review board of the First Affiliated Hospital of Chongqing Medical University (number 2019–062). The need for written, informed consent was waived by the institutional review board of the First Affiliated Hospital of Chongqing Medical University because of the retrospective design.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eCompeting interests\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eAuthors’ contributions\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eZRL and BJF collected, analyzed, and interpreted the patient data, and were equal major contributors in writing the manuscript. YX and YSL provided the study materials and data, and wrote the manuscript. ZGC monitored the process of the study, made conception, and designed the research and modified the manuscript. All authors read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eFunding\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThis work was supported by the Joint Project of Chongqing Science and Technology\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eCommission and Chongqing Public Health Commission (2022MSXM050), and the Senior Medical Talents Program of Chongqing for Young and Middle-aged from Chongqing Health Commission (Receptor: Zhigang Chu)\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eAvailability of data and materials\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets used and/or analyzed during the current study are not publicly available because the cases are from the Picture Archiving and Communicating System of our Hospital but are available from the corresponding author on reasonable request.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003e\u003cspan\u003eTorres A, Cilloniz C, Niederman MS, et al. Pneumonia [J]. Nat Rev Dis Primers. 2021;7(1):25.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eLanks CW, Musani AI, Hsia DW. Community-acquired Pneumonia and Hospital-acquired Pneumonia [J]. Med Clin North Am. 2019;103(3):487\u0026ndash;501.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eNeill S, Dean N. Aspiration pneumonia and pneumonitis: a spectrum of infectious/noninfectious diseases affecting the lung [J]. Curr Opin Infect Dis. 2019;32(2):152\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eBledsoe TJ, Nath SK, Decker RH. Radiation Pneumonitis [J]. Clin Chest Med. 2017;38(2):201\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eBurke M, Fraser R. Obstructive pneumonitis: a pathologic and pathogenetic reappraisal [J]. Radiology. 1988;166(3):699\u0026ndash;704.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eRolston KVI, Nesher L. Post-Obstructive Pneumonia in Patients with Cancer: A Review [J]. Infect Dis Ther. 2018;7(1):29\u0026ndash;38.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eAbers MS, Sandvall BP, Sampath R, et al. Postobstructive Pneumonia: An Underdescribed Syndrome [J]. Clin Infect Dis. 2016;62(8):957\u0026ndash;61.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eBajaj D, Sachdeva A, Deepak D. Foreign body aspiration [J]. J Thorac Dis. 2021;13(8):5159\u0026ndash;75.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eRolston KV. Postobstructive Pneumonia in Cancer Patients [J]. Clin Infect Dis. 2016;63(5):707\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eValvani A, Martin A, Devarajan A, et al. Postobstructive pneumonia in lung cancer [J]. Ann Transl Med. 2019;7(15):357.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eBlanco Ramos M, Botana-Rial M, Garc\u0026iacute;a-Font\u0026aacute;n E, et al. Update in the extraction of airway foreign bodies in adults [J]. J Thorac Dis. 2016;8(11):3452\u0026ndash;6.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eTseng H-J, Hanna TN, Shuaib W et al. Imaging Foreign Bodies: Ingested, Aspirated, and Inserted [J]. Ann Emerg Med, 2015, 66(6).\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eRisal R, Aung HM, Jahir T, et al. Endobronchial Foreign Bodies Presenting as Intermittent Chest Pain and Productive Cough [J]. Cureus. 2022;14(9):e29599.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eLin L, Wang Y, Zha X, et al. Cayenne aspiration: an unusual type of lower airway foreign-body aspiration [J]. Clin Interv Aging. 2014;9:2019\u0026ndash;25.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eHewlett JC, Rickman OB, Lentz RJ, et al. Foreign body aspiration in adult airways: therapeutic approach [J]. J Thorac Dis. 2017;9(9):3398\u0026ndash;409.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eLin L, Lv L, Wang Y, et al. The clinical features of foreign body aspiration into the lower airway in geriatric patients [J]. Clin Interv Aging. 2014;9:1613\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eSumanth TJ, Bokare BD, Mahore DM, et al. Management of tracheobronchial foreign bodies: a retrospective and prospective study [J]. Indian J Otolaryngol Head Neck Surg. 2014;66(Suppl 1):60\u0026ndash;4.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eLai Y, Huang J, Zhou X, et al. Regional dietary characteristics and bronchial foreign body: a repeated misdiagnosis caused by a red pepper [J]. J Thorac Dis. 2017;9(3):E180\u0026ndash;E2.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eSehgal IS, Dhooria S, Ram B, et al. Foreign Body Inhalation in the Adult Population: Experience of 25,998 Bronchoscopies and Systematic Review of the Literature [J]. Respir Care. 2015;60(10):1438\u0026ndash;48.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eReddy RZ, Carter YM, Hsia DW. Successful Removal of a Chronic Aspirated Foreign Body after Twelve Years [J]. Case Rep Pulmonol, 2018, 2018: 8241591.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eRamos MB, Fern\u0026aacute;ndez-Villar A, Rivo JE, et al. Extraction of airway foreign bodies in adults: experience from 1987\u0026ndash;2008 [J]. Interact Cardiovasc Thorac Surg. 2009;9(3):402\u0026ndash;5.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eMa W, Hu J, Yang M, et al. Application of flexible fiberoptic bronchoscopy in the removal of adult airway foreign bodies [J]. BMC Surg. 2020;20(1):165.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eNg J, Kim S, Chang B, et al. Clinical features and treatment outcomes of airway foreign body aspiration in adults [J]. J Thorac Dis. 2019;11(3):1056\u0026ndash;64.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eDong Y-C, Zhou G-W, Bai C, et al. Removal of tracheobronchial foreign bodies in adults using a flexible bronchoscope: experience with 200 cases in China [J]. Intern Med. 2012;51(18):2515\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eGupta A, Shah A. Bronchial anthracofibrosis: an emerging pulmonary disease due to biomass fuel exposure [J]. Int J Tuberc Lung Dis. 2011;15(5):602\u0026ndash;12.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eByrd RB, Carr DT, Miller WE, et al. Radiographic abnormalities in carcinoma of the lung as related to histological cell type [J]. Thorax. 1969;24(5):573\u0026ndash;5.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eChoi JA, Kim JH, Hong KT, et al. CT bronchus sign in malignant solitary pulmonary lesions: value in the prediction of cell type [J]. Eur Radiol. 2000;10(8):1304\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eZissin R, Shapiro-Feinberg M, Rozenman J, et al. CT findings of the chest in adults with aspirated foreign bodies [J]. Eur Radiol. 2001;11(4):606\u0026ndash;11.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eTorres de Amorim e Silva CJ, Fink AM. Case 137: Pneumonia and bronchiectasis secondary to unrecognized peanut impaction [J]. Radiology. 2008;248(3):1080\u0026ndash;2.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eWalker CM, Rosado-de-Christenson ML, Mart\u0026iacute;nez-Jim\u0026eacute;nez S, et al. Bronchial arteries: anatomy, function, hypertrophy, and anomalies [J]. Volume 35. Radiographics: a Review Publication of the Radiological Society of North America, Inc; 2015. pp. 32\u0026ndash;49. 1.\u003c/span\u003e\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Obstructive pneumonia, Foreign body, Pepper, Computed tomography","lastPublishedDoi":"10.21203/rs.3.rs-3175550/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-3175550/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003ePurpose:\u003c/strong\u003e To investigate the computed tomography (CT) characteristics of bronchopulmonary abnormalities caused by pepper aspiration for improving diagnosis.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMaterials and methods:\u003c/strong\u003e From January 2016 to September 2022, 28 adult patients with confirmed obstructive pneumonia caused by pepper aspiration were enrolled. The CT characteristics of bronchial changes and pulmonary lesions caused by pepper were analyzed and summarized.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults: \u003c/strong\u003eAmong the 28 patients, the most common symptom was cough (26, 92.9%), followed by expectoration (23, 82.1%). Bronchoscopy examination revealed that the pepper was mainly located in the right lower lobe bronchus (18, 64.3%), followed by the left lower lobe bronchus (5, 17.9%). In combination with bronchoscopy results, the pepper in bronchus was manifested as circular or V/U-shaped high density, localized soft tissue, and flocculent opacification in 8 (28.6%), 16 (57.1%), and 3 (10.7%) cases on CT images, respectively. The bronchial wall around the pepper was thickened with localized occlusion (19, 67.9%) and stenosis (9, 32.1%). Regarding the adjacent bronchi without pepper, extensive wall thickening with stenosis and/or occlusion were found in 23 (82.1%) cases. Distal pulmonary lesions frequently involved two or three segments (21, 75.0%) and mainly presented as patchy consolidation or atelectasis (24, 85.7%).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion:\u003c/strong\u003e In combination to history of eating pepper and clinical symptoms, bronchopulmonary abnormalities caused by pepper should be highly suspected if U/V shaped and annular high density or localized soft tissue density was detected in the lower lobe bronchus, with extensive bronchial wall thickening, stenosis, or occlusion, and consolidation or atelectasis in multiple distal lung segments.\u003c/p\u003e","manuscriptTitle":"CT characteristics of bronchopulmonary abnormalities caused by pepper aspiration","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2023-07-24 14:27:46","doi":"10.21203/rs.3.rs-3175550/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"4182baec-ba85-4ccc-a3b9-04a2725f1dad","owner":[],"postedDate":"July 24th, 2023","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2024-03-22T01:21:35+00:00","versionOfRecord":[],"versionCreatedAt":"2023-07-24 14:27:46","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-3175550","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-3175550","identity":"rs-3175550","version":["v1"]},"buildId":"FbvkV6FR0MCFSLy54lSbu","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}